Dubowitz Howard, Feigelman Susan, Lane Wendy, Kim Jeongeun
Department of Pediatrics, University of Maryland School of Medicine, 520 W Lombard St, Baltimore, MD 21201, USA.
Pediatrics. 2009 Mar;123(3):858-64. doi: 10.1542/peds.2008-1376.
Effective strategies for preventing child maltreatment are needed. Few primary care-based programs have been developed, and most have not been well evaluated.
Our goal was to evaluate the efficacy of the Safe Environment for Every Kid model of pediatric primary care in reducing the occurrence of child maltreatment.
A randomized trial was conducted from June 2002 to November 2005 in a university-based resident continuity clinic in Baltimore, Maryland. The study population consisted of English-speaking parents of children (0-5 years) brought in for child health supervision. Of the 1118 participants approached, 729 agreed to participate, and 558 of them completed the study protocol. Resident continuity clinics were cluster randomized by day of the week to the model (intervention) or standard care (control) groups. Model care consisted of (1) residents who received special training, (2) the Parent Screening Questionnaire, and (3) a social worker. Risk factors for child maltreatment were identified and addressed by the resident physician and/or social worker. Standard care involved routine pediatric primary care. A subset of the clinic population was sampled for the evaluation. Child maltreatment was measured in 3 ways: (1) child protective services reports using state agency data; (2) medical chart documentation of possible abuse or neglect; and (3) parental report of harsh punishment via the Parent-Child Conflict Tactics scale.
Model care resulted in significantly lower rates of child maltreatment in all the outcome measures: fewer child protective services reports, fewer instances of possible medical neglect documented as treatment nonadherence, fewer children with delayed immunizations, and less harsh punishment reported by parents. One-tailed testing was conducted in accordance with the study hypothesis.
The Safe Environment for Every Kid (SEEK) model of pediatric primary care seems promising as a practical strategy for helping prevent child maltreatment. Replication and additional evaluation of the model are recommended.
需要有效的预防儿童虐待策略。基于初级保健的项目很少，且大多数未得到充分评估。
我们的目标是评估儿童初级保健的“为每个孩子创造安全环境”模式在减少儿童虐待发生率方面的效果。
2002年6月至2005年11月在马里兰州巴尔的摩市一家大学附属的住院医师连续性诊所进行了一项随机试验。研究人群包括带孩子（0至5岁）前来进行儿童健康监护的讲英语的家长。在1118名被邀请的参与者中，729人同意参与，其中558人完成了研究方案。住院医师连续性诊所按星期几进行整群随机分组，分为模式组（干预组）或标准护理组（对照组）。模式护理包括：（1）接受过特殊培训的住院医师；（2）家长筛查问卷；（3）一名社会工作者。住院医师和/或社会工作者识别并处理儿童虐待的风险因素。标准护理包括常规的儿童初级保健。对诊所人群的一个子集进行抽样评估。通过以下三种方式衡量儿童虐待情况：（1）使用州机构数据的儿童保护服务报告；（2）可能存在虐待或忽视的病历记录；（3）通过亲子冲突策略量表家长报告的严厉惩罚情况。
在所有结局指标中，模式护理导致儿童虐待发生率显著降低：儿童保护服务报告减少，因治疗不依从记录的可能医疗忽视情况减少，免疫接种延迟的儿童减少，家长报告的严厉惩罚减少。根据研究假设进行了单尾检验。
儿童初级保健的“为每个孩子创造安全环境”（SEEK）模式作为一种有助于预防儿童虐待的实用策略似乎很有前景。建议对该模式进行复制和进一步评估。
